PBS News Hour

Medicaid covers nearly 104 million medical visits, but that may soon change

By JoNel Aleccia, Kaiser Health News January 30, 2018

Driver Donavan Dunn loads Maddie Holt into the van on Nov. 21, 2017. The only way Maddie and her mother, Meagan Holt, can make the trip to the hospital is by using a service provided by Medicaid called non-emergency medical transportation, or NEMT. (Heidi de Marco/KHN)

EVERETT, Wash. — Unable to walk or talk, barely able to see or hear, 5-year-old Maddie Holt waits in her wheelchair for a ride to the hospital.

The 27-pound girl is dressed in polka-dot pants and a flowered shirt for the trip, plus a red headband with a sparkly bow, two wispy blond ponytails poking out on top.

Her parents can’t drive her. They both have disabling vision problems; and, besides, they can’t afford a car. When Maddie was born in 2012 with the rare and usually fatal genetic condition called Zellweger syndrome, Meagan and Brandon Holt, then in their early 20s, were plunged into a world of overwhelming need — and profound poverty.

“We lost everything when Maddie got sick,” said Meagan Holt, now 27.

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care.

Multiple times each month, Maddie sees a team of specialists at Seattle Children’s Hospital who treat her for the condition that has left her nearly blind and deaf, with frequent seizures and life-threatening liver problems.

The only way Maddie can make the trip, more than an hour each way, is through a service provided by Medicaid, the nation’s health insurance program started more than 50 years ago as a safety net for the poor.

Called non-emergency medical transportation, or NEMT, the benefit is as old as Medicaid itself. From its inception, in 1966, Medicaid has been required to transport people to and from such medical services as mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and, in Maddie’s case, visits to specialists.

“This is so important,” said Holt. “Now that she’s older and more disabled, it’s crucial.”

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care. The numbers have grown dramatically since the program expanded in 32 states plus the District of Columbia to cover prescription drugs, health screening for children, breast and cervical cancer treatment and nursing home care.

With a Republican administration vowing to trim Medicaid, Kaiser Health News is examining how the U.S. has evolved into a Medicaid Nation, where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid’s role in transportation is a telling example. Included in the NEMT coverage are nearly 104 million trips each year at a cost of nearly $3 billion, according to a 2013 estimate, the most recent, by Texas researchers.

Citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.

Already, states have wide leeway in how to provide and pay for the transportation.

Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don’t include transportation.

They also contend that changes will help curb what government investigators in 2016 warned is “a high risk for fraud and abuse” in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) reported that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn’t have medical needs for ambulance transportation. And the mother of a Medicaid patient who was authorized to transport her child for treatment billed Medicaid for trips that didn’t take place. She was sentenced to 30 days in jail and ordered to pay $21,500.

At least three states, Iowa, Indiana and Kentucky, have received federal waivers — and extensions —allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Last March, Rep. Susan Brooks, an Indiana Republican, introduced a resolution that would have revoked the federal requirement to provide NEMT in an effort to provide states with “flexibility.” That effort stalled.

Another Republican proposal in 2017 would have reversed the Affordable Care Act’s Medicaid expansion and reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.

Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation’s governors to consider NEMT waivers, among other actions, in a March letter to them.

“We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges,” they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration’s more expansive health policies, and has granted some states’ requests.

At least three states, Iowa, Indiana and Kentucky, have received federal waivers — and extensions —allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Critics of the cuts worry the trend will accelerate, leaving poor and sick patients with no way to get to medical appointments.

“I wouldn’t be surprised to see more of these waivers in the pipeline,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Because medical transportation isn’t typically covered by the commercial insurance plans most Americans use, it’s unfamiliar to many people and could be seen as unnecessary, said Eliot Fishman, senior director of health policy for Families USA, a nonprofit, nonpartisan consumer health advocacy group.

Formerly a Medicaid official in the federal government, Fishman called the transportation program “vital” not only for children with severe disabilities, but also for non-elderly, low-income adults.

CMS released results of a 2014 survey of Medicaid users, which found that lack of transportation was the third-greatest barrier to care for adults with disabilities, with 12.2 percent of those patients reporting they couldn’t get a ride to a doctor’s office.

“This is not something to be trifled with lightly,” Fishman said. “We’re talking about a lifesaving aspect of the Medicaid program.”

“This is not something to be trifled with lightly. We’re talking about a lifesaving aspect of the Medicaid program.”

About 3.6 million Americans miss or delay non-emergency medical care each year because of transportation problems, according to a 2005 study published by the National Academy of Sciences.

That same study analyzed costs for providing NEMT to patients facing 12 common medical conditions and found that providing additional transportation is cost-effective. For four of those conditions — prenatal care, asthma, heart disease and diabetes — medical transportation saved money when the total costs for both transportation and health care were tallied.

Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation, whether that’s taxis, vans or public transit.

Most states rely on NEMT brokers or managed-care organizations to administer the transportation services. Other states run the service directly, paying providers on a per-ride basis, while some use local ride services and pay independent taxi firms to shuttle patients.

Proponents of revamping NEMT note that disabled children like Maddie and other people with serious disabilities are in little danger of losing services. In Iowa and Indiana, Medicaid transportation remains available to several groups of patients, including those classified as “medically frail,” though the definition of who qualifies can vary widely.

In addition, one managed-care provider, Anthem, continues to transport Indiana Medicaid patients, despite the waiver that was first enacted in 2007.

Still, Medicaid clients like Fallon Kunz, 29, of Mishawaka, Ind., are often stuck. Kunz, who has cerebral palsy, migraine headaches and chronic pain, uses a power wheelchair. When she was a child, she qualified for door-to-door service to medical appointments, she said.

Today, she lives with her father, whose home is outside the route of a Medicaid transit van. Getting to and from medical appointments for her chronic condition is a constant struggle, she said. Taxis are too expensive: $35 each way for a wheelchair-enabled cab.

“The majority of our patients are in survival mode.”

“The only way I can get rides to and from my doctor’s appointment is to ride the 2 miles in my wheelchair, despite all kinds of weather, from my home, across the bridge, to the grocery store,” she said. “Right outside the grocery store is the bus stop. I can catch the regular bus there.”

Sometimes, she’s in too much pain or the Indiana weather — warm and humid in the summer, frigid and windy in the winter — is too much to battle and she skips the appointment.

“Today I didn’t go because it was too cold and my legs hurt too much,” she said on a December Tuesday. “I didn’t feel like getting blown off the sidewalk.”

In Maddie Holt’s case, she was shuttled to Seattle Children’s on a rainy Tuesday morning in a medical van driven by Donavan Dunn, a 47-year-old former big-rig trucker. He works for Northwest Transport, one of several regional brokers that manage NEMT services for Washington state.

Dunn said he received special training to transport patients like Maddie, who is loaded onto a motorized platform, wheelchair and all, into the van and then carefully strapped in.

“I have to drive different,” said Dunn. “I have to watch my corners, watch my starts, watch my stops. It’s always in the back of my mind that I have somebody on board that’s fragile.”

The transportation service can be used only for medical visits to the specialists who treat Maddie’s condition, which is caused by mutations in any one of at least 12 genes. If Meagan Holt needs to pick up prescriptions or get groceries, she leaves Maddie and a second daughter, Olivia, 3, at home with their dad and takes the bus or walks to her destinations.

Caring for a severely disabled child is not the life she expected, Meagan Holt said, but she cherishes time with Maddie, who has learned to communicate through tactile sign language spelled into her hand.

Maddie is one of hundreds of NEMT-eligible children transported to Seattle Children’s each month. Last September, for instance, more than 1,300 clients made more than 3,600 trips at a cost of more than $203,000, according to the Washington Health Care Authority, which oversees the state’s Medicaid program called Apple Health.

The need is so great, in fact, that the hospital created a transportation will-call desk to help organize the comings and goings.

“When we realized how much transportation is a barrier to getting to your appointment, we decided to do something about it,” said Julie Povick, manager of international exchanges and guest services at Seattle Children’s.

But Verma, the architect of Indiana’s Medicaid overhaul plan, has suggested that too much handholding might be “counterproductive” for patients — and bad for the country.

In a 2016 Health Affairs essay, Verma noted that early analysis of the effects of curtailing NEMT in Indiana showed that more Medicaid patients with access to the program said transportation was a primary reason for missed appointments than did members without access.

“Moreover, 90 percent of [Healthy Indiana Plan] members report having their own transportation or the ability to rely on family and friends for transportation to health care appointments,” she wrote.

But Marsha Simon, a Washington, D.C., health policy consultant who has tracked NEMT for years, said Medicaid is the option of last resort. People who are able to get rides on their own already do.

“If 90 percent can and 10 percent can’t, what about the 10 percent?” Simon said.

It’s a question that haunts Kunz every day.

“I’m a college student, I have a cat,” said Kunz, who is studying psychology online at Southern New Hampshire University. “I’m just a regular human trying to do things, and the inaccessibility in this area is ridiculous.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. You can view the original report on its website.

Members of the House and Senate Agriculture Committees are starting to shape the 2018 Farm Bill–a comprehensive food and agriculture bill passed about every five years. Most observers associate the farm bill with food policy, but its conservation section is the single largest source of funding for soil, water, and wildlife conservation on private land in the United States.

Sixty percent of U.S. land is privately owned, and it contains a disproportionately high share of habitat for threatened and endangered species. This means that to conserve land and wildlife, it is critical to work with private landowners, particularly farmers and ranchers. Farm bill conservation programs provide cost shares, financial incentives, and technical assistance to farmers and other private landowners who voluntarily undertake conservation efforts on their land.

President Donald Trump’s 2019 budget request would slash funding for farm bill conservation programs by about $13 billion over 10 years, on top of cuts already sustained in the 2014 Farm Bill. In a recent study, we found that it is highly uncertain whether the benefits these programs have produced will be maintained if they are cut further.

Jim and DeAnn Sattelberg received Conservation Reserve Program funding to plant ‘filter strips’ that protect water sources on their Michigan farm. (Photo credit: USDA)

Congress made substantial cuts in farm bill conservation programs in 2014–the first reductions since the conservation title of the bill was created in 1985. In total, the 2014 farm bill reduced conservation spending by 6.4 percent, or about $3.97 billion over 10 years.

These cuts reduced the number of farmers who were able to enroll in the programs. For example, the Conservation Reserve Program pays farmers to take environmentally sensitive land out of agricultural production and convert cropland into ecologically beneficial grasses. In 2016, due to budget cuts, it accepted just 22 percent of acres that farmers offered for enrollment.

The Conservation Stewardship Program, which focuses on working lands in agricultural production, offers farmers financial incentives and technical advice for conservation measures such as cover crops or efficient irrigation systems. In 2015 USDA funded only 27 percent of CSP applications.

In a June 2017 hearing, Sen. Pat Roberts, R-Kan., chairman of the Senate Committee on Agriculture, Nutrition, and Forestry, said:

“I’ve heard repeatedly from farmers and ranchers about the importance of these programs, how they successfully incentivize farmers to take conservation to the next level, and the need for continued federal investment in these critical programs.”

In October 2017, Sens. Debbie Stabenow, D-Mich. and Joni Ernst, R-Iowa, introduced a bipartisan bill to strengthen the Regional Conservation Partnership Program, which fosters private-public partnerships in regions of high conservation priority. The Trump administration has proposed to eliminate this program, along with the Conservation Stewardship Program.

Funding will be tight for the 2018 Farm Bill, as USDA has acknowledged. A set of guiding principlesthe department released on January 24 pledged to provide “a fiscally responsible Farm Bill that reflects the Administration’s budget goals.” Congress will soon face funding decisions that will have critical implications for conservation outcomes and landowners.

Without Funding, Fewer Farmers Will Conserve

Further budget cuts in farm bill conservation programs would undermine environmental protection in multiple ways. Less land and wildlife would be protected, and fewer farmers would be able to enroll in these programs. Moreover, as our study concluded, landowners are unlikely to continue their conservation efforts when payments end.

Federal agencies and environmental organizations generally would like to see owners keep up conservation practices even when they no longer receive federal incentives. We call this phenomenon “persistence.” Designing incentives so that they produce lasting behavior changes is a challenge in many fields, including agricultural conservation.

Our search of relevant scientific publications found very limited research on landowner behavior after incentive program contracts end. What research has been done indicates that persistence is highly variable and often does not occur.

Studies have found that after contracts expire, the percentage of landowners who continue conservation management can range from 31 to 85 percent. Persistence also depends on the practices landowners are required to perform. Structural actions like planting trees are more likely to have lasting effects than measures that landowners need to perform frequently and may abandon, such as treating invasive plants with herbicides.

Little is known about why landowners do or do not persist with conservation behaviors after incentive programs end. But we have identified several mechanisms that could support persistence behavior.

As landowners participate in conservation programs, they might develop positive views of conservation. They also may continue to use conservation practices because they want to be perceived as good land stewards. Practices that involve repeated action, such as moving cattle for prescribed grazing, might become habits. Finally, landowners with sufficient financial and technical resources are more likely to persist with conservation behaviors.

Long-Term Costs Of Defunding Conservation Programs

Our research shows that it is hard to predict how farmers and ranchers will respond if they are unable to re-enroll in farm bill conservation programs. Some might continue with conservation management, but it is likely that many landowners would resume farming formerly protected land or abandon conservation practices.

To promote conservation more effectively over time, it would make sense to consider farm bill policy changes such as issuing longer-duration contracts and designing post-contract transitions that encourage continued conservation. Further budget cuts will only reduce future conservation on private land, and could undo much of the good that these programs have already achieved.

EcoWatch

World’s First Floating Wind Farm Exceeds Expectations

The world’s first floating wind farm only switched on three months ago but it’s already performing better than expected—and that’s despite a hurricane, a powerful winter storm and waves as high as 8.2 meters (27 feet).

The 30-megawatt Hywind Scotland, located about 15 miles off the Aberdeenshire coast, churned out 65 percent of its maximum theoretical capacity during November, December and January, according to its operator, Statoil.

In comparison, the typical capacity factor for a bottom fixed offshore wind farm is 45-60 percent during the same winter months, Statoil pointed out.

“We have tested the Hywind technology in harsh weather conditions for many years and we know it works,” said Beate Myking, senior vice president of offshore wind operations in Statoil.

“It is very encouraging to see how well the turbines have performed so far. Hywind Scotland’s high availability has ensured that the volume of electricity generated is substantially higher than expected.”

These results show great promise for the emerging technology. As EcoWatch previously detailed, floating turbines have been deployed before, but mostly in small-scale projects, such as the 7-megawatt system built and operated by the Fukushima Wind Offshore Consortium. In contrast, the Hywind’s five floating turbines produce 6 megawatts each on top of waters more than 328 feet deep. At full capacity, the facility can generate enough power for 20,000 homes.

As Bloomberg explained, typical offshore wind farms are installed on seabeds in relatively shallow seas. But with a floating system, countries like Japan, the U.S. West Coast, and the Mediterranean—where seabeds drop steeply off the coast—can also utilize the technology.

Statoil sees “great potential” to build more floating wind farms on top of waters around 200 feet in depth, even in areas with extreme environments and weather conditions. In October, the Hywind survived Hurricane Ophelia‘s 77 mph winds. It then faced even stronger winds in December, with Storm Caroline’s 100 mph gusts and walls of large waves. Although the farm’s wind turbines were shut down during the worst of these winds, they automatically resumed operations afterwards, Statoil said.

“Knowing that up to 80 percent of the offshore wind resources globally are in deep waters (+60 meters) where traditional bottom fixed installations are not suitable, we see great potential for floating offshore wind, in Asia, on the west coast of North America and in Europe,” said Irene Rummelhoff, executive vice president for New Energy Solutions in Statoil.

The developers are looking to expand the technology and hope to reduce the costs of energy to €40-60 ($50-$75)/MWh by 2030, making it cost competitive with other renewable energy sources. The cost of onshore and offshore wind has seen significant reductions in recent years, with the UK’s latest renewable energy auction dropping to 57.50 pounds ($76) per megawatt-hour, Bloomberg noted.

“This is an ambitious, but realistic target. Optimized design, larger and more efficient turbines, technology development and larger wind parks will drive down costs, improve infrastructure and logistics,” Rummelhoff said.

ars technica – Max Effect

A solar panel on every roof in the US? Here are the numbers

When you’re scoping out possible futures, it’s useful to ask a lot of “what if?” questions. For example, what if we could install solar panels on every suitable roof in the United States? How much electricity would they generate?

Plenty of research has followed this line of thought, though much of it has necessarily focused on working out the details for individual cities or regions. But now with enough of these studies in the bank, a group of researchers from the US National Renewable Energy Laboratory decided to take another whack at a national estimate.

There are a lot of things you need to know to do this: number of buildings, size of roofs, direction the roofs are facing, strength of sunlight, number of sunny days, and so on. So first off, the researchers took advantage of a Department of Homeland Security program that laser-maps buildings, which now covers almost a quarter of buildings in the US. From this, it’s possible to get roof area, roof tilt, roof direction, and whether the roof is shaded by trees. Roofs were tossed out if they were too small, too steep, north-facing, or otherwise would lose more than 20 percent of their possible solar output, but most roofs were suitable.

To estimate the rest of the country, the researchers calculated statistics for the covered area and then used things like Census data to scale them for every other ZIP code area.

Next, the researchers worked out the average amount of sunlight in a year for each location. Using the average efficiency of rooftop solar panels installed in 2015, they combined everything to produce a map of maximum possible rooftop solar energy production.

In total, they estimate that there are a little over 8 billion square meters of suitable roofs in the US. Cover that in solar panels, and you would produce about 1,400 terawatt hours of electricity each year—about two-thirds of which would come from small residential buildings. The total production is equal to nearly 40 percent of the total electricity currently sold by utilities in the US.

A simpler 2008 National Renewable Energy Laboratory estimate came in at just 22 percent of electricity—the new estimate shows a higher percentage partly because solar panel efficiency has improved but also because new sources of data made a more accurate estimate possible.

Enlarge/ Total estimated rooftop solar production by state (top), also shown as a percentage of total electricity use (bottom).

Gagnon et al/Environmental Research Letters

Apart from the big numbers, there are some interesting details at the state or local level. States with strong sunlight and plenty of roofs obviously have the most potential—California, for example, could supply 74 percent of its total electricity use by covering its buildings with solar panels, while Wyoming could only get to about 14 percent.

But that’s partly because of different electricity use. New England doesn’t have the sunniest skies, but the limited need for air conditioning in the summer helps keep electricity use down. As a result, that region could produce about half its total electricity from rooftop solar. And if you consider residential buildings separately, they can produce about as much electricity as people use in their homes.

Overall, the all-in scenario of slapping solar panels on every single building wouldn’t be enough to replace all our power plants, but 40 percent ain’t bad. More plausible (and less Fiddler-on-the-Roof-If-I-Were-a-Rich-Man) scenarios would obviously stay south of that number. Still, the “what if?” is instructive.

The only real way to build the economy is through rise-up economics — not trickle-down economics. Investment in American workers — in their health care, job training, and education — is the key to economic growth, not tax cuts for the rich and corporations. Our latest video explains why we must put an end to trickle-down nonsense.

HuffPost

EPA Says Scott Pruitt Flies First Class Because Angry People Yell At Him Too Much

Nick Visser, HuffPost February 16, 2018

Often costing thousands of dollars more than equivalent seats in coach. The report, citing EPA receipts obtained through a Freedom of Information Act request, noted several flights cost more than $90,000 in total during a few weeks last June.

Federal regulations mandate government employees travel in the “least expensive class of travel” for their needs, but individuals are allowed to book premium seats if there are security concerns.

The EPA briefly said this week Pruitt had a “blanket wavier” to travel first class but later rolled back its statement when Politico noted that the regulations state that such travel must be approved on a “trip-by-trip basis.” A spokesman later clarified to the news site that Pruitt’s office submitted a waiver seeking an exemption before each trip, citing security concerns.

Until Thursday’s report, it was unclear what those concerns were, although Pruitt defended the bookings in an interview with the New Hampshire Union Leader, blaming what he called a “very toxic environment politically.”

“We’ve reached the point where there’s not much civility in the marketplace and it’s created, you know, it’s created some issues and the (security) detail, the level of protection is determined by the level of threat,” he told the Union Leader on Tuesday.

Pruitt’s tenure at the EPA over the past year has been controversial among environmentalists. The agency has quickly worked to roll back many regulations meant to combat climate change. The agency has also moved to unravel the Clean Water Act and the Clean Power Plan, and Pruitt was one of the driving forces behind President Donald Trump’s decision to withdraw the U.S. from the landmark Paris climate deal.

He receives many more threats than his predecessors, E&E News reported in January, and is the first EPA administrator to have a full-time security detail.

The agency also refuses to release many details about Pruitt’s schedule in advance, citing similar security concerns.

PolitiFact

Counting up how much the NRA spends on campaigns and lobbying

How influential is the National Rifle Association? We took a closer look.

Since the mass shooting in Las Vegas, there has been much discussion about the National Rifle Association’s influence on gun policy.

In late-night host Jimmy Kimmel’s monologue about Las Vegas and the influence of the gun industry, he charged that Senate Majority Leader Mitch McConnell, House Speaker Paul Ryan and other lawmakers “won’t do anything about this because the NRA has their balls in a money clip.”

New York Times columnist Bret Stephens pushed back at that notion in his “Repeal the Second Amendment” column, suggesting that gun control advocates were overstating the NRA’s money footprint.

“The National Rifle Association does not have Republican ‘balls in a money clip,’ as (late-night TV host) Jimmy Kimmel put it the other night,” Stephens wrote. “The NRA has donated a paltry $3,533,294 to all current members of Congress since 1998, according to The Washington Post, equivalent to about three months of Kimmel’s salary. The NRA doesn’t need to buy influence: It’s powerful because it’s popular.”

We found that Stephens’ characterization, while accurate, doesn’t reflect the true scope of the organization’s political heft.

“Assessing the NRA’s political spending solely by its donations to congressional candidates leaves millions in spending out,” said Alex Howard, deputy director of the Sunlight Foundation, which tracks transparency and influence in politics and policy.

For this report, we drilled further into the NRA’s political spending — including lobbying and outside spending in races — to offer a more comprehensive view of its influence in Washington.

(The NRA didn’t respond to an inquiry for this article.)

Direct candidate contributions are not the whole story

The claim of $3.5 million in donations is based on credible data, but narrow.

The Washington Postdatabase summarizes NRA contributions to current members of Congress, searchable by state and lawmaker, going back to 1998. (The Post database revised its total for NRA contributions to $4.23 million on its last update on Oct. 5, the same day Stephens’ column was published.)

The Post structured its database in a way to make it easy for readers to search for how much their representative or senator received from the NRA.

That means the database won’t allow searches for NRA donations to previous members of Congress who were serving for a portion of that almost 20-year period. If you include these members, the amount of contributions increases substantially.

The Post’s focus on members of Congress also means it doesn’t include NRA donations to candidates for federal offices other than Congress, or to parties or party committees.

If you add together all of the NRA’s contributions to candidates, parties and leadership political action committees between 1998 and 2016, it comes to more than $13 million, according to calculations from the Center for Responsive Politics’ database.

That’s more than three and a half times larger than their direct contributions to current members of Congress.

But there’s more.

NRA spends millions more intervening in campaigns and lobbying

The NRA’s biggest chunk of spending on politics came from “outside spending,” consisting largely of “independent expenditures” — efforts “expressly advocating the election or defeat of a clearly identified candidate.” Often these take the form of campaign ads, but they are carried out without coordinating with the candidates they are supporting.

This type of spending vastly outpaces what the NRA spent on giving to candidates directly. The NRA spent $144.3 million on outside spending, such as independent expenditures, during that period.

In addition, the NRA since 1998 has reported spending a cumulative $45.9 million on federal lobbying, both for its in-house operations and the outside consultants it has retained.

If you add it all up — candidate and party contributions, independent expenditures, and lobbying — the NRA has spent $203.2 million on political activities since 1998.